Application Form to Operate an Electric Fishing Device

We recommend that you contact your usual permissions advisor, or the appropriate Department of Conservation Office to discuss the application prior to completing the application forms. Please provide all information requested in as much detail as possible. Applicants will be advised if further information is required before this application can be processed by the Department. Once you have filled in your application form, please complete this checklist to ensure that all components of your application are complete. This will help prevent any possible delays in the processing of your application:

 Enclosed credit Application Form.

 Copies of management plans that relate to the site (for the reserves under the Reserves Act 1977, or land administered under the Conservation Act 1987 or any Act listed in the first schedule of the Conservation Act 1987).

A. Applicant Details

Applicant Name (full name of registered company, institute, organisation, or individual) Legal Status Registered Research of applicant Individual Trust Company Institute (tick) 1 Other (please specify full details)

Trading Name (if different from Applicant name) Postal Address

Street Address (if different from Postal Address

1 For all other than Individual please attach proof of legal status e.g. company registration information; trust deed registration information and label Attachment A.

Docdm-1450285 )

Register ed Office of Compan y or Incorpor ated Society (if applicab le) Websit Phone e Contact Person and role Cell Phone Phone Email

B. Area and Details of Proposed Activity 1. Describe the area(s) of your operation in detail (for example, waterway/body, track names and hut names; include town/region names), if necessary attach map or polygon file. Identify the status of the area(s) (i.e. national park, conservation area, forest park, nature or recreation reserve, etc). Information about the classification of land managed by DOC can be found on the DOC website: http://www.doc.govt.nz/about-doc/role/maps-and-geospatial-services/ The names of the DOC regions are also on the DOC website: http://www.doc.govt.nz/about- doc/structure/regions/ 2. What is the proposed activity and reasons for wanting to undertake it? Include method details, machine type(s), animal welfare considerations, biosecurity procedures, and health and safety procedures to protect members of the public:

Commercia Purpose Research Educational l of Activity Use Relevant Experience / Training of the Applicant

List Names of all Certified Users of an electric fishing device and their Involvement

Alternative Proposed To Dates Dates

C. Identification of Actual and Potential Effects of Proposed Activity Please describe the direct and indirect effects that your proposal will have on the conservation values. Failure to complete this section may result in a decline of your application. All activities have effects.

1. Describe the effect of your activity on the habitat or particular species (include considerations such as spawning habitat, fish passage, substrate, riparian vegetation and ground nesting birds):

2. Do you intend to keep and/or kill any specimens of freshwater fauna taken as a result of your activity? Specify species, numbers, reason and method for keeping and/or killing:

Docdm-1450285 3. Describe any disturbance of native vegetation, soils, wetlands, waterway/body substrate or any other natural feature:

4. What wildlife species are either within or near the area where you want to operate:

5. List any historical or archaeological sites in the area where you want to operate:

6. What aspects of your activity will be visible from within or adjoining the area(s) where you want to conduct your activity? Please explain:

7. Is it possible that your activity will introduce terrestrial or aquatic weeds, (either by fragment or seeds), or invasive fish or invertebrate species into the area? Please explain: 8. What is the risk of fire from your activity? Please explain:

9. What noise will be caused by your activity? Please explain:

10. Is there any aspect of your activity that will affect current or future public access to the area(s)? Please explain:

11. What effects will your activity have on plants, animals or sites of traditional importance to Māori and who have you consulted over this matter?

12. Will your activity have any positive effects on natural or historic values? Please explain:

Docdm-1450285 13. Will your activity promote understanding of conservation? Please explain:

D. Measures to Avoid, Remedy or Mitigate

Where you have identified actual or possible adverse effects in your description, please also describe the actions you propose to take to avoid, remedy or mitigate those effects.

Example: Plants and/or eggs may be introduced on equipment. Proposed action to avoid this: washing of all equipment before and after work at all sites, using established protocols such as those developed by Biosecurity New Zealand.

E. Fees Processing Fees:

Section 60B of the Conservation Act 1987 contains the statutory provisions regarding processing fees. The Department recovers all direct and indirect costs to process an application from Applicants regardless of whether the application is approved or declined. The cost of processing depends on whether the application is standard or complex. The current estimated cost of processing a standard application for aquatic life transfers is $400 plus GST. For particularly complicated applications further costs may be incurred for components such as extended iwi consultation and/or extra technical expert advice. In this situation the Applicant will be sent an estimate of costs. Applicants are also entitled to request an estimate of costs at any point but the Department may impose a charge for preparing such an estimate. Estimates are not binding. The Department will ordinarily invoice the Applicant for processing fees after a decision has been made on the application, but in some cases interim invoices will be issued. If at any stage an application is withdrawn the Department will invoice the Applicant for the costs incurred by the Department up to that point. Applicants are required to pay the processing fees within 28 days of receiving an invoice. The Director-General is entitled to recover any unpaid fees as a debt. If you are applying as a student of a University, or the professor of a student, and you have authorisation that the University will pay the fees then you must provide the Department with a purchase order/number. If you don’t have a purchase order/number and/or you require an invoice for payment please fill in the Credit Application Form with your own information. The Director-General of Conservation has discretion to reduce or waive processing fees. The Department may obtain further information either from the applicant or from any other relevant source in order to process the application. The applicant will be advised of any information obtained from other sources. The cost of obtaining such information will be charged to and recovered from the applicant. The applicant will be informed as soon as practicable from receipt of the application if further information is required before this application form can be fully processed by the Department.

Docdm-1450285 DECLARATION

I certify that the information provided on this application form and all attached additional forms and information is to the best of my knowledge true and correct. Note: An Authorisation may be varied or revoked if the information given in this application contains inaccuracies.

Signature Date (Applicant)

Signature Date (Witness)

Witness Name

Witness Address

This application is made pursuant to Section 26ZR of the Conservation Act 1987.

Applicants should familiarise themselves with the relevant provisions of the Conservation Act 1987.

The purpose of collecting this information is to enable the Department to process your application. The Department will not use this information for any reason not related to that purpose.

Applicants should be aware that provisions of the Official Information Act might require that some or all information in this application be publicly released. CREDIT APPLICATION FORM Application for a Credit Account with the Department of Conservation (All fields must be completed)

Date of Full Legal Name: Birth: Trading Name: Licence Version Driver Licence Number: Number: GST Registration Company Number: Registration Number:

Trading Address: (Physical address can not be a PO Box) Post Code:

Address for Invoice/ Statement: (Postal Address) Post Code: Email Address: Phone Number: Fax Number: Mobile Contact Person: Number: Partnership Limited Sole Trader: : Company: If partnership or limited company provided details for owners, partners and/or directors: Full Names: (incl. DOB), driver licence number, addresses, home phone numbers of owners, partners and/or directors. Have you held an account with the Department before? Yes No Under what name: Area:

Please turn over to complete the Terms and Conditions

Docdm-1450285 Terms and Conditions for an Account with the Department of Conservation: Trade References Telephone Number Contact Person These are referees that supply you with goods or services on standard business terms i.e. 20th of month following supply not banks, electricity suppliers, landlords etc. (1 )

If you have not held an account with the Department before, please supply 3 trade references below.

1. I/We agree that the Department of Conservation can provide my details to the Department’s Credit Checking Agency to enable it to conduct a full credit check. 2. I/We agree that any change which affects the trading address, legal entity, structure of management or control of the applicant’s company (as detailed in this application) will be notified in writing to the Department of Conservation within 7 days of that change becoming effective. 3. I/We agree to notify the Department of Conservation of any disputed charges within 14 days of the date of the invoice. 4. I/We agree to fully pay the Department of Conservation for any invoice received on or before the due date. 5. I/We agree to pay all costs incurred (including interest, legal costs and debt recovery fees) to recover any money owing on this account. 6. I/We agree that the credit account provided by the Department of Conservation may be withdrawn by the Department of Conservation, if any terms and conditions of the credit account are not met. 7. I/We agree that the Department of Conservation can provide my details to the Department’s Debt Collection Agency in the event of non-payment of payable fees. Signed: Name:

Designation: Date:

For Departmental use Credit check completed Comments :

Signed: Name: Approved: Name: Note: Approval is to be by a Tier IV Manager or above.